Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Wednesday, June 27, 2012

Recently I received an email alerting me to an important survey conducted by CARE about sex and alcohol use on overnight college visits for high school student applicants. I admit that despite practicing pediatrics for over 20 years, and having a high school senior in the thick of the college application process, I have not previously given this issue a moments thought. Certainly it seemed worthy of a blog post! The email read:

Roughly one in six surveyed teens (16 percent) who had been on an overnight college admissions visit reported drinking alcohol during the visit. Teens also reported engaging in sex or other intimate sexual behavior (17 percent), using drugs other than alcohol (5 percent) or driving while impaired (2 percent) during their overnight college visit.

The study, conducted for CARE(Center for Adolescent Research and Education) and SADD(Students Against Destructive Decisions) by ORC International Inc. surveyed 1,070 U.S. teens from age 16 to 19, 270 of whom indicated they’d been on an overnight college admissions visit. It includes high school students currently making college visits and current college students reflecting on previous visits. Data was collected online between April 17 and 20, 2012.

Most concerning, in my opinion, is that for half of those kids, it was their first experience with sex or alcohol. This suggests that high schoolers visiting college may a particularly vulnerable group. They may be initiated into the world of college life before they are quite ready for it. Below is a quote from A Higher Education, the Psychology Today blog post by Stephen Wallace, director of CARE:

New research from the Center for Adolescent Research and Education (CARE) at Susquehanna University and SADD (Students Against Destructive Decisions) reveals that more than half (51 percent) of high school overnight visitors who reported drinking alcohol on campus (about one in six) report having done so for the first time. Among those who reported having sexual intercourse (12 percent of those participating in an overnight visit), half (50 percent) said this had been the first time they had done so.

With regards to sexual encounters, it is quite likely, given the circumstances, that these are one time affairs. Such an experience may have negative consequences, particularly in the setting of emerging sexual identity.

The whole college application process challenges teenagers to focus, in what can and should be a healthy way, on their emerging sense of self and unique identity. For parents, offering background support and letting the child, with the help of college advisors, guide the process, is an excellent approach.

This survey, however, has opened my eyes to an issue that warrents parental involvement. Wallace offers some guidelines about addressing this issue, for both parents and teens. Every family has its own unique ways of communicating. My hope is that in calling attention to the issue, it will help to prevent college bound teenagers from getting themselves into uncomfortable or unhealthy situations.

Wednesday, June 20, 2012

In my behavioral pediatrics practice, it is not uncommon for parents to go to great lengths to put up a good front. They feel terrible shame about moments of out-of-control behavior, and also fear that I will blame them for their child's troubles. They focus primarily on "what to do" about their child's difficult behavior. However with time, and the realization that I am interested in understanding, not shaming or blaming, they begin to open up about their own life and the enormous stress they experience in their parenting role. They acknowledge that this stress has often led them to yell at their kids or even remove themselves emotionally.

An important new study published in the current journal of the American Academy of Child and Adolescent Psychiatry provides evidence that a parent's early life stress, such as abuse, emotional neglect, or emotional abandonment, lives in the parent's body. The reactions mothers (the study is just about mothers, though fathers certainly face similar challenges) may have in the face of a child's aggressive or clingy behavior are biologically based. It is not simply that they are hitting because they were hit. The authors of the study draw on extensive animal research showing biological mechanisms for transmission of parenting behavior.

For example, when a child behaves aggressively in a way that is developmentally normal (though limits must be set) a parent with a history of early life trauma may have a surge of stress hormones that affect the functioning of his or her brain. Thinking is impaired. He or she may have a kind of fight-or-flight reaction, which may lead to aggression in return. Another alternative is to shut down, or in psychological language to "dissociate." This leads to that sense of being emotionally disconnected. Neither are good for a child.

This study has major implications for understanding as well as treatment. If a parent is frequently out-of-control, and is yelling at or hitting a child, or emotionally removing him or herself, it must be addressed. Focusing exclusively on the child's behavior will accomplish little in this situation. Repeated exposure to an angry, out-of-control or emotionally removed parent has significant impact on development.

If parents can recognize that early life trauma has led to this kind of biological reaction, it may eliminate some of the guilt and shame. It may encourage them to acknowledge and address the problem. When children are young, there is ample opportunity to turn things in a better direction.

Second, if the problem is in the parents' body, treatment needs to involve working with the parents body. Psychotherapy can be important as a way to develop insight into the impact early life experience. But this kind of work can take time. A more immediate intervention involves helping a parent to recognize the stress reaction and then to develop tools to combat it.

I am not talking about medication. While medication may calm a parent down, and may be necessary in some cases, the hope is to identify the way a child's behavior provokes a parent, and develop strategies for remaining calm in the moment. The mindfulness movement has much to offer in this regard. Deep breathing, yoga or simply a short walk can help to calm the body down. Music or art will work better for others.

When parents come to my office asking what to do about their child's "problem behavior," I don't think they expect that my answer will be "go for a walk." I am pleased that this current study will support me when in fact I do say something like that.

Saturday, June 16, 2012

This post is dedicated to my friend David, who passed away on June 13th after a battle with leukemia, leaving behind two young daughters. While we have not been in touch for many years, we reconnected around his illness. We were roommates in medical school, and were very close before he moved to the West coast and life took us in different directions. Recently I spoke with a mutual friend, also a father of two girls, who is godfather to one of David's daughters. He described horsing around with the girls in the pool on a recent visit shortly before David died. Both David and my friend are athletes, and I could vividly picture the physical nature of David's relationship with his girls, and the important role our mutual friend will now play in their lives.

In my behavioral pediatrics practice I always encourage fathers to participate, and am most grateful when they come for visits. Sometimes a mother has been dealing with with postpartum depression, and the father can offer a unique perspective. Other times, the father himself has been struggling emotionally, and we are able to address these issues and their relevance to parenting. In a previous post Supporting Fathers Emotional Health, I address this issue in detail. The bottom line is that fathers have an essential role to play in supporting a child's healthy emotional development.

Recently I was interviewed for an article in Parenting Magazine about things not to say when a child is having a tantrum. One was, "Just wait till your father gets home!" While threats of this nature are never good, recognizing being "at the end of one's rope," and in such a moment drawing on the support of a perhaps more level headed partner is an excellent idea.

I never met David's wife, but my heart goes out to her. In addition to the grief of this terrible loss, she now is faced with the challenging task of managing these inevitable parenting moments without her other half to balance things out. l know from the chain of emails about his illness that there is an extensive support network of family and friends to take up that role. I hope she will make good use of them.

David is still very much alive in my mind. I have vivid memories of him as a thoughtful, smart and really funny person. While I never saw him in his father role, I am certain that he was much more to his daughters than a great playmate. Father's day will be one of many difficult days ahead for this young family. I know those close to them will help them to hold on to their many wonderful memories of David.

In celebration of his spirit, I give thanks for the fathers in my life- both the father of my children and my own father. I hope others will do the same.

Sunday, June 10, 2012

As a general and behavioral pediatrician I admit that I have participated in many conversations that went something like this. In a child's presence a parent says: "He does well in his morning classes, but then his grades are down in the afternoon-can we use something longer acting?" Or, "She did so well at first, but now she's getting 70's. I think she needs a higher dose." These conversations occurred in the setting of a brief follow-up visit for ADHD. These visits might be spread as far apart as 3 to 6 months. What else happened in those months? There was neither the time nor the expectation to address that question in a meaningful way.

Is it any surprise, given that this form, length and frequency of visits for ADHD is the standard of care in pediatrics, that now there is an explosion of abuse of prescription stimulants in the high pressure setting of the college application process? A recent New York Times article Risky Rise of the Good-Grade Pill addressing this issue states:

The number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly, according to IMS Health, a health care information company — a number that experts estimate corresponds to more than two million individuals. But there is no reliable research on how many high school students take stimulants as a study aid. Doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent.

My daughter is a senior at one of these "high-pressure private schools" referred to in the article. She confirms these statistics, putting the number at about one third. A previous post, Meds for ADHD: They Work But is that the Right Question?, was inspired by conversation in which she asked me about the ethics of taking these drugs for the SATs. In that post I speak to the need to understand ADHD as a problem regulation of attention, emotion and behavior, and to focus on relationship-based interventions to promote self-regulation. It is the hyperfocus on medication to the exclusion of both understanding of the child's experience, and also other forms of intervention, that has led to this problem in the high school setting.

Relationship-rich interventions include such things as martial arts, music, and team sports (Michael Phelps had severe ADHD), activities that foster relationships and also promote self-regulation. Family systems are often severely strained when a child is struggling, and interventions aimed at supporting the family as a whole are very important. Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.

When I asked my daughter today if she had ever taken stimulants before a test she replied that she thought it was a silly idea. Her reason? "If you do well on stimulants it's not really you, and you will end up at a college where you will be miserable. Then you will need to keep taking the drugs." Such a wise child!

Wednesday, June 6, 2012

My 51st birthday is approaching. My father is 87 years old. Yet it was not until this spring that I learned details of the story of his childhood in Nazi Germany, his escape to America as a teenager, and his dramatic rescue of his parents from the concentration camp Theresienstadt when he returned to Germany as a soldier with the United States army. It took his grandson, my 13-year-old son, to get him to break this silence, when my son requested that his grandfather speak to his 8th grade class following their visit to the Holocaust museum in Washington, DC.

My father's story is one of not only survival, but of triumph in the midst of unimaginable horror. He would never use the word "trauma" to describe his experience. Bits of the story had emerged at times, in part around my daughter's bat-mitzvah 4 years earlier. But in general he ascribed to Elie Weisel's notion that it was a horror so great it could not be spoken of.

French psychoanalysts Francoise Davoine and Jean-Max Gaudilliere have a different adage on the cover of their book, History Beyond Trauma; "Whereof one cannot speak, thereof one cannot stay silent." They argue that personal stories of war and societal trauma, if not told in words, emerge as symptoms, sometimes as mental illness, sometimes in subsequent generations.

Davoine offers a wonderful example in a story of her own family. She and her husband were on a trip with their young children when she discovered a growth in her abdomen. Despite a fear of cancer, they decided to say nothing to their children and finish the month-long trip. Shortly after the discovery, her son developed severe anxiety around bedtime and refused to go to sleep. It emerged that, being highly sensitive to his parents emotions, as children can be, he was worried, but didn't know what to be afraid of. When his parents explained about the lump, his sleep problem resolved. They write:

Let us imagine, for a moment, the following catastrophic scenario: continuing to play the admirable mother, Francoise keeps the secret. The child would find himself burdened by the cut out truth of the story. Rushing into a hyperactive exploration, or barricaded in a hyperpassive withdrawal, nowadays he might have been quickly diagnosed and chemically brought back to reason.

In my behavioral pediatrics practice, I often hear stories like this from parents, both of major trauma in the form of such things as abuse or death of a sibling, or subtler trauma of having an emotionally troubled parent. At first parents focus on the child's "behavior problem." But in a non-judgmental atmosphere where sufficient time is given, parents are usually eager talk about their own history, and become curious about the effects of their experience on themselves as parents, and on their child.

For example, a 4-year-old girl had severe separation anxiety. It emerged that her mother had a miscarriage when she was three, and had never had the opportunity to mourn the loss. Her daughter was worried about her, and so did not want to leave her either to go to school or go to sleep. A father of another boy with "defiant behavior." had been abused by his own father, and found himself full of explosive rage that came out, against his will, in his relationship with his young son.

In recent posts I have been focusing on qualities a child brings to the relationship with his parents. In our quest to understand a child's experience, this is an essential piece. But equally important is to understand what parents bring to the relationship, in particular in terms of their own unique history. Parent-child relationships are a complex, intricate dance. At times they can be clumsy and full of stepped on toes. But with work and careful attention, they can be transformed back into a dance of joy and grace.

I am blessed by the fact that my father is alive and in good health. I am hopeful that we now have the opportunity to write a book together telling of both his remarkable life, and also how his experience came to be known by me and my children. It will serve as a dramatic example of a story that needs to be told.

the baby connects

About Me

I am a pediatrician and writer with a long-standing interest in addressing children’s mental health needs in a preventive model. I have practiced general and behavioral pediatrics for over 20 years, and currently specialize in early childhood mental health. I am the author of Keeping Your Child in Mind and the forthcoming The Silenced Child (Da Capo, spring 2016) and The Developmental Science of Early Childhood: Clinical Application from Birth through Adolescence (Norton.) I am a graduate of the UMass Boston Infant-Parent Mental Health Post-Graduate Certificate Program, and I am on the faculty of the Brazelton Institute, the Berkshire Psychoanalytic Institute and the Austen Riggs Center.